Provider Demographics
NPI:1427317817
Name:FORD, MARY JANE (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:FORD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23232 PERALTA DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1443
Mailing Address - Country:US
Mailing Address - Phone:714-390-0713
Mailing Address - Fax:949-707-5100
Practice Address - Street 1:23232 PERALTA DR
Practice Address - Street 2:SUITE 211
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1443
Practice Address - Country:US
Practice Address - Phone:714-390-0713
Practice Address - Fax:949-707-5100
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48928106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist